Background: POCUS is increasingly being used across medical specialties, and adds value to diagnostic accuracy for numerous pathologies and levels of acuity. Emergency Medicine providers were early adapters, providing examples of how POCUS increases patient satisfaction and diagnostic clarity (1, 2). Internal Medicine and Family Medicine have been slower to adopt this technology; however, general medicine provides many opportunities for POCUS use (3, 4). Training is currently offered through major societies, but residency training is limited by the availability of supervising POCUS competent attendings and ultrasound machines. A consultative service circumvents these limitations while providing education and services to the primary team.
Purpose: We designed a consultative service to answer POCUS based clinical questions across 14 internal medicine and family medicine inpatient services at a tertiary academic medical center, while concurrently developing a certified training opportunity for residents. Residents were highly encouraged to build an image portfolio that, if completed, would qualify them for independent clinical practice by graduation and serve as faculty for future elective sessions.
Description: Internal medicine residents (n=13) participated in a two-week elective training course in POCUS skills. The elective began with a two-day “boot camp” of didactics and hands-on practice using standardized patients. These residents formed the POCUS consult team and used focused cardiac, pleural/lung, abdominal, and deep venous exams to answer consult questions from inpatient medicine teams. These questions included evaluation of cardiac function and causes of hypoxia, hypotension, and acute kidney injury.Residents used hand-held ultrasounds to employ their newly developed skills and respond to consult questions independently in the mornings. This was followed by formal “gel rounds” in the afternoons with one of four rotating POCUS competent faculty supervisors. During gel rounds, faculty and residents would refine image acquisition using higher resolutions ultrasound machines, integrate findings into the patient’s clinical presentation with the primary team, and follow-up on diagnostic or therapeutic changes as a result of their exams. The major limitation was POCUS competent faculty time. While the two-day bootcamp was time-intensive, this was offset by using a consultative model with residents scanning independently in the morning. Dedicated faculty time was only needed in the afternoon. Finally, future iterations of the elective would deploy POCUS competent residents and fellows as peer trainers.Falling prices of handheld ultrasounds has made machine availability less of an obstacle. However, these pocket ultrasounds result in lower resolution images on smaller screens making them less ideal for teaching. We circumvented this issue by using handheld ultrasounds for independent scanning and only needed more expensive, laptop models for afternoon gel rounds.
Conclusions: A POCUS consult service for a large, tertiary medical center was feasible for effective resident POCUS training with a small number of supervising physicians and a combination of less expensive handheld ultrasound devices and a single portable ultrasound. Resident skill, confidence, and satisfaction increased with this model which also resulted in significant changes in patient care. We propose this model to similar programs seeking to increase inpatient POCUS services and education.